2013/10: Should marijuana be legally available for medical purposes?

What they said...'Why do I need to commit a criminal act to help myself when so many countries ... have embraced the values of marijuana for medical purposes? If the politicians won't let me die with dignity, at least let me live with some'
'Stuart' one of the case studies referred to in the report of the New South Wales Committee investigating medical marijuana

'Although cannabis may cause an immediate euphoric feeling, for a large group in the population its use can lead to an increase of depressive symptoms in the longer term'
Daily Science report, October 13, 2011

The issue at a glance
On May 15, 2013, it was announced that a New South Wales committee had recommended that the use of marijuana be legalised for medical purposes by people with cancer, AIDS or other terminal illnesses.
If the recommendation is approved by the New South Wales government, patients with specific conditions, certified by their specialist doctor, would be allowed to possess and use up to 15 grams of dry cannabis.
The committee's chair, National party upper house member Sarah Mitchel, stated that it was appropriate and compassionate to allow a very small and specific group of people to smoke marijuana.
Opponents of the legalisation of recreational drugs have expressed concern that allowing marijuana to be used for medical purposes could make it more difficult to prevent its use in other contexts.
The New South Wales Government has indicated it is unlikely to allow terminally ill people to legally use small amounts of marijuana, despite the cross-party parliamentary committee unanimously recommending this move.

Background
(This material is abbreviated from a Wikipedia entry titled 'medical cannabis'. The full report can be accessed at https://en.wikipedia.org/wiki/Medical_cannabis)

Medical marijuana (cannabis) refers to the parts of the herb cannabis used as a physician-recommended form of medicine or herbal therapy, or to synthetic forms of specific cannabinoids such as THC (delta-9-tetrahydrocannabinol) as a physician-recommended form of medicine.
The Cannabis plant has a long history of use as medicine, with legendary evidence dating back to the fictional Shen Nung in 2737 BCE. Cannabis is one of the 50 'fundamental' herbs of traditional Chinese medicine, and is prescribed for a broad range of indications.

Extent of use
Medical cannabis is illegal in most countries. A number of governments, including the United States Federal Government, allow treatment with one or more specific low doses of synthetic cannabinoids for one or more disorders. However, public opinion in several areas, including the United States, is swinging in favour of use of medical cannabis, especially for chronically ill patients. The topic is one of great controversy and is being debated more than ever.
Studies have shown cannabis does have several well-documented beneficial effects. Among these are: the amelioration of nausea and vomiting, stimulation of hunger in chemotherapy and AIDS patients, lowered intraocular eye pressure (shown to be effective for treating glaucoma), as well as gastrointestinal illness. It also has antibacterial effects and is one of the best known expectorants.
There are several methods for administration of dosage, including vaporizing or smoking dried buds, drinking, or eating extracts, and taking capsules. The comparable efficacy of these methods was the subject of an investigative study conducted by the National Institutes of Health.
Synthetic cannabinoids are available as prescription drugs in some countries. Examples are Marinol (The United States and Canada) and Cesamet (Canada, Mexico, the United Kingdom, and the United States).
While utilizing cannabis for recreational purposes is illegal in many parts of the world, many countries are beginning to entertain varying levels of decriminalisation for medical usage, including Canada, Austria, Germany, Switzerland, the Netherlands, Czech Republic, Spain, Israel, Italy, Finland, and Portugal. In the United States, federal law outlaws all use of herb parts from Cannabis; States that have approved use of medical cannabis are in conflict with federal law. The United States Supreme Court has ruled in United States v. Oakland Cannabis Buyers' Coop and Gonzales v. Raich that the federal government has a right to regulate and criminalize cannabis, even for medical purposes. A person can therefore be prosecuted for a cannabis-related crime even if it is legal medical use according to state laws. The United States federal government, through the National Institute on Drug Abuse (NIDA), continues to provide medical cannabis to four patients who participated in the Compassionate Investigational New Drug Program. NIDA claims this is done for "compassionate purposes" and the United States federal government still maintains that medical marijuana is not an effective or desirable treatment for any medical condition despite significant contrary evidence.

Clinical applications
A 2002 review of medical literature by Franjo Grotenhermen states that medical cannabis has established effects in the treatment of nausea, vomiting, premenstrual syndrome, unintentional weight loss, insomnia, and lack of appetite. Other "relatively well-confirmed" effects were in the treatment of "spasticity, painful conditions, especially neurogenic pain, movement disorders, asthma, [and] glaucoma".
Preliminary findings indicate that cannabis-based drugs could prove useful in treating adrenal disease, inflammatory bowel disease, migraines, fibromyalgia, and related conditions.
Medical cannabis has also been found to relieve certain symptoms of multiple sclerosis and spinal cord injuries by exhibiting antispasmodic and muscle-relaxant properties as well as stimulating appetite.
Other studies state that cannabis or cannabinoids may be useful in treating alcohol abuse, amyotrophic lateral sclerosis, collagen-induced arthritis, asthma, atherosclerosis, bipolar disorder, colorectal cancer, HIV-Associated Sensory Neuropathy, depression, dystonia, epilepsy, digestive diseases, gliomas, hepatitis C, Huntington's disease, leukemia, skin tumours, methicillin-resistant Staphylococcus aureus (MRSA), Parkinson's disease, pruritus, posttraumatic stress disorder (PTSD), psoriasis, sickle-cell disease, sleep apnoea, and anorexia nervosa. Controlled research on treating Tourette syndrome with a synthetic version of THC called (Marinol), showed the patients taking the pill had a beneficial response without serious adverse effects; other studies have shown that cannabis "has no effects on tics and increases the individual's inner tension". Case reports found that cannabis helped reduce tics, but validation of these results requires longer, controlled studies on larger samples.
A study done by Craig Reinarman surveyed people in California who used cannabis found they did so for many reasons. Reported uses were for pain relief, muscle spasms, headaches, anxiety, nausea, vomiting, depression, cramps, panic attacks, diarrhoea, and itching. Others used cannabis to improve sleep, relaxation, appetite, concentration or focus, and energy. Some patients used it to prevent medication side effects, anger, involuntary movements, and seizures, while others used it as a substitute for other prescription medications and alcohol.

Internet information
On June 2, 2013 the most recent of a series of arguments was posted on a site titled 'Reasons to Oppose "Medical Marijuana" in Arizona: Vote No on Proposition 203'
The site is dedicated to shifting public opinion against a proposal that marijuana be legalised for medical purposes in Arizona.
The most recent posting is titled 'Why marijuana legalization is far from inevitable'
The site contains a range of arguments against the legalisation of medical marijuana. It can be accessed at http://edgogek.com/

On May 16, 2013, The Conversation published an opinion piece titled 'Legalising medicinal cannabis is a leap forward for compassion'
The comment was written by Dr Alex Wodak AM, former Director of the Alcohol and Drug Service, St. Vincent's Hospital, Sydney (1982-2012) and now an Emeritus Consultant.
Dr Alex argues in favour of the legalisation of marijuana possession and use for medical purposes.
The full text can be found at http://theconversation.com/legalising-medicinal-cannabis-is-a-leap-forward-for-compassion-14297

Arguments in favour of marijuana being made legally available for medical purposes
1. Marijuana is an effective means of reducing the distress of those suffering a number of diseases
Marijuana has been shown to beneficial effects in the treatment of a number of serious conditions.
Anecdotal evidence for the beneficial effects of marijuana eventually led to the design of controlled scientific studies to examine the benefits of marijuana compared to other treatments. A 1997 review of 6059 marijuana-related articles in the medical literature revealed 194 titles on antiemetic properties, 56 on glaucoma, 10 on multiple sclerosis, 23 on appetite, and 11 on palliative or terminal care. Numerous studies have been performed since that time, with most concentrating on the analgesic properties of cannabis and its derivatives.
The Cancer Council of New South Wales has stated that cannabis may be of medical benefit to cancer patients where conventional treatments are unsuccessful, in the following circumstances: in relieving nausea and vomiting in patients undergoing chemotherapy; as an adjunctive analgesic in patients with moderate to severe pain; and/or as an appetite stimulant for cancer patients experiencing weight loss and muscle wasting.
Studies have shown that cannabis can relieve muscle pain and spasticity in patients suffering from multiple sclerosis and can control tremors in multiple sclerosis animal models. THC has been shown to reduce intraocular pressure in laboratory animals and humans who have glaucoma.

2. Those using marijuana for medical purposes should not be subject to prosecution
Supporter of decriminalising the medical use of marijuana claim that it is unjust to prosecute and punish people who are merely trying to find relief from the distressing symptoms of a disease.
In an opinion piece published in The Sudbury Sun on May 10, 2011, Linda Crabtree wrote, 'Why do I have to break the law and risk my credibility and reputation to find relief from pain?
If you live in constant pain or have any one of many conditions that can be relieved with the use of marijuana, you'll know why I'm writing this column.'
Ms Crabtree went on to explain, 'I have lived with chronic burning neuropathic pain for almost 20 years. At first I didn't think anyone could live like this, but I have and I've met many people in the same boat. It's a tough way to live. It's stressful; it affects your work, your family and your life. You just hurt all the time.
And then you find something that helps relieve the pain and lets you live a fairly normal life, but you have to jump hoops so high to get it, it's heartbreaking.'
'Stuart', one of the terminally ill patients whose situation was used as a case study by the New South Wales inquiry into the medical use of marijuana was quoted as saying 'Why do I need to commit a criminal act to help myself when so many countries ... have embraced the values of marijuana for medical purposes? If the politicians won't let me die with dignity, at least let me live with some.'
It has been noted that other medications when used in the medical treatment of pain and other symptoms are legally available, though when used recreationally they are outside the law. This is true, for example, of a wide range of opium-derived drugs. Critics argue that it is unjust to make one form of treatment legally available and not another.

3. Medical marijuana would only be made available under controlled conditions
It has been noted that under the terms recommended by the New South Wales Committee, marijuana would only be available in limited quantities and only to those certified by their physician to be suffering from a terminal disease of HIV.
The Committee's recommendations include the following provisions. '[T]hat the defence [against prosecution for marijuana use]be restricted to persons listed on a register of 'authorised cannabis patients and carers', with eligibility contingent upon certification by the patient's treating specialist medical practitioner that the patient is diagnosed with a specified condition.'
The Committee also notes that the amount of cannabis that could be legally consumed would be strictly regulated. '[A] complete defence [would be made available] from arrest and prosecution for the use of cannabis and possession of up to 15 grams of dry cannabis or equivalent amounts of other cannabis products, and equipment for the administration of cannabis, by the patient.' The same immunity from prosecution for this 15 gram amount has also been recommended for the patients' caregivers.

4. Medical marijuana would not result in the legalisation of recreational marijuana
The New South Wales Committee which has recommended the legalisation of marijuana for medical use made it plain that it did not support the recreational use of the drug and does not see its medical use as a precursor to more general use.
The committee's chairwoman, National Party upper house member Sarah Mitchell, has said, 'We recognise the risks and negative effects of crude cannabis use, particularly via smoking, and by no means do we endorse the recreational use of cannabis.'
The Committee did not recommend its use for chronic pain or decriminalising marijuana cultivation for personal use, and acknowledged the issue of obtaining cannabis was difficult.
It has also been noted that approving the medical use of marijuana does not automatically lead to increased recreational use within the community.
Referring to the American situation, it has been noted that the fear that medical marijuana laws would increase adolescent recreational use of the drug has not come true.
According to the official California Student Survey teen marijuana use in California rose steadily from 1990 to 1996, but began falling immediately after the medical-marijuana law was passed in 1996.
Among ninth graders, marijuana use in the last six months fell by more than 40 percent from 1995-96 to 2001-02 (the most recent available figures).
It has also been noted that the 1998 National Household Survey on Drug Abuse released by the United States Department of Health and Human Services, indicates that medical marijuana reform does not lead to increased non-medical marijuana use.

5. A majority within the Australian community support the use of marijuana for medical purposes
It has been noted that a very large majority of the Australian public is in support of marijuana being made legally available for medical purposes.
The Committee's report included the following observation, 'The Committee notes public opinion in relation to medical cannabis, with 69 per cent of people in a recent Australian Institute of Health and Welfare survey indicating that they support legislation to allow medical use of cannabis, matched with 74 per cent of participants showing support for clinical trials investigating the benefits of cannabis for medical conditions.'
Looking at Australia as a whole, in the 2010 National Drug Strategy Household Survey Report 68.8% of people aged over 14 years supported the legalisation of medical marijuana. 74% supported clinical trials.
Similar trends have been noted in other jurisdictions. A 2013 poll by Siena Research Institute found that 82 percent of New Yorkers supported allowing seriously and terminally ill people to legally use marijuana for medical purposes if recommended by a doctor.
A large number of patients also support the legalisation of marijuana use for medical purposes.
A study of 128 Australians who risk legal consequences to take marijuana reported 'great relief' for a variety of conditions. The most common reasons given for use were depression and chronic pain relief. Many of them had tried all available legal alternatives before turning to cannabis to treat their symptoms. They also reported fewer side effects. Their greatest concern with their use of the drug was its illegal status.
90% of participants had informed their doctor of their therapeutic use with 75% receiving a positive response and their families also supported them in 71% of cases.
There was almost universal support amongst medical marijuana users for increased research into the therapeutic benefits of the drug and for alternative methods of administration.

Arguments against marijuana being made legally available for medical purposes
1. There are many health risks associated with the use of marijuana for medical purposes
Taking marijuana has been associated with a number of health risks.
Although smoking marijuana does not have the same degree of risk as smoking tobacco (because of the frequency of usage), smoking anything over long periods of time does add to risks of contracting forms of cancer of the respiratory tract. Studies have suggested that smoking marijuana increases the risk of both oral cancers and lung cancer.
Some studies have suggested that marijuana might be a trigger for adverse cardiovascular events, including tachyarrhythmias, acute coronary syndrome, and vascular complications, especially in older users, and may be a risk factor in congenital heart defects for their children. It has also been implicated as a possible precursor of strokes. Ischemic stroke is found almost exclusively in people of advanced age. However a number of reports have shown an association between cannabis abuse and ischemic stroke in young people.
Marijuana users generally have poorer oral health than non-users, with an increased risk of dental caries (cavities) and periodontal diseases, along with dysplastic changes and pre-malignant lesions within the oral mucosa. In addition, users are prone to oral infections, possibly due to immunosuppressive effects.

2. Medical marijuana use would expose patients to increased road accident risks
Marijuana has been shown to have a number of adverse effects on drivers.
Laboratory studies examining the effects of marijuana (cannabis) on skills utilised while driving detected impairments in tracking, attention, reaction time, short-term memory, hand-eye coordination, vigilance, time and distance perception, decision making, and concentration. More recent controlled laboratory research has suggested similarly that cannabis impairs tasks of selective and divided attention, time estimation, and executive function.
Marijuana is the second most common drug (found in about 15% of fatalities in Victoria), followed by the amphetamine-type stimulants (4%) and opioids (4%). Illicit drugs are present in almost 20% of drivers killed in Victoria. A survey of almost 500 injured drivers admitted to a major road trauma hospital found that cannabis products were present in 46%, opioid analgesics in 11% and amphetamines in 4%.3
It is recognised that a number of prescribed medications are already contributing to increased road accident rates. Critics of the medical use of marijuana claim that such use would only make the existing problem worse.

3. Medical marijuana may increase anxiety and depression
One of the main arguments against the medical use of marijuana is that it does not produce Serotonin, but affects anandamide which is present in brain and produces soothing feeling by reacting with THC which is present in marijuana.
This can actually increase depression and cause schizophrenia which has been noted a side-effect regular, prolonged illegal use.
Opponents of the medical use of marijuana note that while it is always safer to administer antidepressant under medical care than use the illegal substance. The constituents of marijuana interfere with the process of balancing the chemicals which antidepressants work to achieve and so may aggravate the condition instead of curing it.
On October 13, 2011, Science Daily reported 'Although cannabis may cause an immediate euphoric feeling, for a large group in the population its use can lead to an increase of depressive symptoms in the longer term.'
In a report published in the British Medical Journal in November, 2002, it was noted that an Australian study of 1,600 14- and 15-year-olds found that the young women who had used marijuana weekly as teenagers were twice as likely to have depression as a young adult than women who did not use the drug. Daily use as a teenager was associated with four times the risk of depression for young women.
It has also been claimed that long-term marijuana use leads to structural changes in the brain that can cause serious mental problems. One study showed hippocampal volume in cannabis users was inversely correlated with cumulative exposure to the drug in the left hemisphere-a finding that suggests 'the left hippocampus may be particularly vulnerable to the effects of cannabis exposure and may be more closely related to the emergence of psychotic symptoms.'

4. Supporters of marijuana decriminalisation are exploiting the medical marijuana argument
It has been claimed that many of those promoting the legal use of marijuana are merely trying to shift community attitudes as a way of having recreational use decriminalised.
In 1979, Keith Stroup, the director of the Unites States National Organization for the Reform of Marijuana Laws (NORML), told an audience at Emory University that NORML would be using medical marijuana as a 'red herring to give marijuana a good name.' Stroup explained the strategy when he said, 'We are trying to get marijuana reclassified medically.'
Kevin Zeese of the United States Drug Policy Foundation was quoted on several occasions as saying, 'Medical marijuana is the first step to decriminalization.' Eric Sterling of the Criminal Justice Foundation has further said, 'Medical use of marijuana is an integral part of the strategy to legalize.'
It has been claimed that supporters of the decriminalisation of marijuana are using public sympathy for those suffering terminal diseases as a means of shifting popular perceptions in favour of marijuana.

5. Medical marijuana use would promote wider use of marijuana within the community
It has been argued that the legalisation of marijuana use for medical purposes will serve to normalise the use of the drug and thus encourage its use within the wider community.
Dr Yu-Wei Chu of Michigan State University's 2012 study on the apparent effects of legalising the use of marijuana for medical purposes supports this claim. Dr Yu-Wei Chu has stated, 'My results indicate a 10-20% increase in marijuana arrests and treatments after the passage of medical marijuana laws...A 10-20% changes in marijuana and heroin use represent large legalization effects.'
It has further been noted that recreational use of marijuana is likely to increase after the drug has been legalised for medical purposes because patient share their supply with friends and family members.
Research has shown that medical marijuana diversion is a significant problem among adolescents in Colorado, which has had legal use of marijuana for medical purposes since November 2000. A study of teenagers being treated for substance abuse, found that nearly 75% of participants reported using another person's medical marijuana a median of 50 times. In addition, use of marijuana was perceived by most adolescents as having 'slight or no risk'.
A report prepared by Family Voice Australia for the New South Wales parliamentary committee investigating the medicalization of marijuana noted, 'Legalising marijuana for medical use combines the risks of increasing availability and normalising of drug- taking behaviour, leading to a greater frequency of marijuana-taking at an earlier age, increased abuse and dependency, and more 'conduct disorder' symptoms among adolescents.'

Further implications
Though the New South Wales government is unlikely to endorse the recommendations of the parliamentary committee which investigated and finally argued for the medical use of marijuana, the issue is unlikely to simply disappear. There is pressure from both patients and some within the medical committee for marijuana to be available as a treatment drug.
The long term solution appears to be to process marijuana as other treatment drugs are processed. This would remove concerns about uniformity and purity and ensure robust regulation. It would also make a clear division between the medical use of marijuana, via tablet or inhalant, and the recreational use of marijuana, usually via smoking or ingesting the raw leaf.
The New South Wales parliamentary committee stated, 'Turning specifically to pharmaceutical cannabis products, we see this as a promising and workable area of reform, not least because such products are by definition subject to a robust regulatory system. Their active ingredients and doses are standardised and their unwanted effects are able to be controlled. In addition, pharmaceutical cannabis products are more acceptable to many individual patients, to the broader community and of course from a law enforcement perspective. Significantly, the product nabiximols (under the trade name Sativex) has demonstrated effectiveness is now available for prescription in Australia for the treatment of a highly specific condition, muscle spasticity arising from multiple sclerosis. While the Committee explicitly does not endorse any particular pharmaceutical product, we recognise that this is presently the only pharmaceutical cannabis product on the horizon for which there is an evidence base that can be recognised by the TGA.'
This is an area that will need careful development as the pharmaceutical cannabis currently available is not as effective as the raw product in treating some disease symptoms. It was also require clear legal authorisation before pharmaceutical companies will begin establishing the authorised supply chains necessary and then undertaking the necessary research.
Under the recommendation of the New South Wales Committee, those who supplied marijuana, even for medical purposes, would still be liable to prosecution. If the drug is to be supplied, produced by pharmaceutical companies, then a legal supply network would have to be established.